The history of maternity care – knowing the journey matters

The starting point for this post is an article about birth, from The Guardian, in December 2014. It was published in response to the updated clinical guideline NICE CG190 Intrapartum Care – care of healthy women and their babies during childbirth.

The Guardian article:
http://www.theguardian.com/society/2014/dec/03/hospital-childbirth-misconception-home-reversing-nice-guidelines

We talked about this article on the #MatExp Facebook group in September this year. This is an edited version of what I said in reply to concerns there that the tone of the article might be seen as offensive towards the medical profession:

For those who have read Marjorie Tew’s ‘Safer childbirth?’, this piece is mild – and in keeping with Joanna Moorhead’ s typically thorough and balanced journalistic approach (clearly here presenting a personal opinion piece). She has long written on birth, and the history of maternity care, and she knows her stuff. Marjory Tew was a statistician, with no axe to grind, when she started teaching medical students about statistics in the 1970s, using maternity outcomes statistics as illustrative data.

When Marjory explored the available figures, she was shocked at what she found. While there is some debate about the interpretation of the data she highlighted, essentially she was right in the argument that she made in her book ‘Safer childbirth?’, published in 1998. The belief that ‘care overseen or managed by doctors in a hospital obstetric unit – or being right next door to the obstetric unit – is safest for all women and all babies, in outcome terms’ is simply not supported by the best available research evidence. (Why this belief was promoted and acted upon is explored in an article by historian Angela Davies, listed in the Resources section below.)

Better research evidence has kept accumulating. The NICE Intrapartum Care 2014 recommendations (for healthy women and babies) draw on more evidence than the Birthplace in England study, which was published in 2011. The research evidence in the NICE ‘planning place of birth’ systematic reviews, which informed the recommendations made, is international. The advice given to women about which places of birth are particularly suitable for them, depending on whether they have had a baby before or are having a first baby, is based mostly on Birthplace. This is because NICE recognised that women would value evidence and advice based on their particular situation.

Had Marjory been alive still on publication day, I would have written to her. I served as a Lay Member on the Guideline Development Group, and I think that her work was important in raising awareness of the need for better evidence. I wish I could have said to her:

  • that being woman-centered and ‘doing the science properly’ has always mattered in maternity – and that these are ‘NICE values’
  • that I believe there is a good chance that multidisciplinary working involving women can make these values more than aspirations, and ‘just what we do’
  • that there is still much to be done, but I hope that she would be pleased, and interested, reading the full guideline chapter on planning place of birth
  • a huge ‘thank you’ for her part in the story so far.

The updated NICE guideline provides evidence-based recommendations, information and advice for healthy women planning their place of birth. ‘Information for the public’ to help women and their families understand the recommendations is available here:

NICE CG190 Information for the public – choosing where to have your baby

Other links & resources:

Historian Angela Davies on the move to hospital:
Choice, policy and practice in maternity care since 1948

Grimes – A Personal Odyessy (about electronic fetal monitoring using CTG machines, crucial to the story of the move into hospital – see also NICE CG190 full guideline chapter 10 p445):
http://www.jameslindlibrary.org/articles/discovering-the-need-for-randomized-controlled-trials-in-obstetrics-a-personal-odyssey/

The Preface to the second edition of ‘Safer Childbirth?’ http://ow.ly/U6nvi

A review of ‘Safer Childbirth?’
http://fampra.oxfordjournals.org/content/16/3/321.2

Peter Brocklehurst, epidemiologist, talking about the Birthplace Study:
https://www.youtube.com/watch?v=MP0oQjXFPio&app=desktop

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